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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
388
CHAPTER12 The lower jaw andface
cPathological fractures ofthe lowerjaw
These are rare, accounting for <2% of all fractures of the mandible. They
are dened as fractures that occur in regions where the bone has been
weakened by an underlying pathological process. These include:
• Surgical interventions (third molar removal and implant placement)
• Osteomyelitis
• Osteoporosis
• ORN
• BRONJ
• Large cystic lesions
• Benign, malignant, or metastatic tumours.
Treatment of pathological fractures can be challenging and complex.
Diagnosis radiologically in the emergency setting then urgent referral is
required.
cAcute sicklecell
The most important pathological event of sickle cell anaemia is vascular
occlusion resulting in ischaemia. Pain is typically disproportionately severe.
Other sites may be aected. Patients presenting with a sickle cell crisis
need IV uids, analgesics, and ox ygen to prevent fur ther sick ling of the
cells. Although the pain may be in the mandible, this is a medical emergency, not a maxillofacialone.
cOsteomyelitis
See E ‘Infective swellings around the lower jaw and face’, pp. 366–72.
bORN/ BRONJ
See E ‘Non- infective swellings around the lower jaw and face’, pp. 372–5.
cAltered sensation ofthe lowerlip
Patients who present acutely with a non- trauma- associated altered sensation
of the lower lip need to be assessed carefully. Many of the ser ious condi-
tions outlined previously in this chapter can be associated with numbness. These include:
• Tumours
• Cystic lesions
• ORN
• Osteomyelitis
• Pathological fractures
• Paget’s disease
• Central haemangiomas/ intraosseousAVM
• BRONJ
• Iatrogenic injury.
All patients who present acutely with altered sensation of the lip following jaw surgery should have plain radiography to exclude a pathological
fracture. Rarely, the ‘numb chin’ presentation can be a presentation of
a paraneoplastic neurological disorder and can be associated with breast,
ovarian, and lung cancer.
Chapter13
389
The mouth, lips, andteeth
Common presentations 390
Common problems and their causes 391
Useful questions and what to look for 402
Examination of the mouth, lips, tongue, teeth, and gums 408
Investigations 411
Injuries to the teeth 413
Soft tissue injuries 415
Bleeding (non- traumatic) 416
Ulceration and blistering 418
Swellings 424
Pain and numbness in the mouth 428
Toothaches and the wisdom teeth 429
The extracted tooth:socket problems 433
Exposed bone 434
Denture and orthodontic appliance- related problems 436
390
CHAP TER13 The mouth, lips, andteeth
Common presentations
Common presentations for the mouth, lips, andteeth:
Thelips
• Change in colour/ pigmented lesions
• Injuries
• Lumps/ swelling
• Pain and numbness
• Ulceration and blistering
• Weak ness or paralysis (see also E ‘Facial palsy’, pp. 340 –2).
Themouth
• Bleeding
• Change in colour/ pigmented lesions
• Diculty swallowing (see E Chapter 8)
• Halitosis
• Injury
• Lumps (see also E Chapter 11 and E Chapter 12)
• Pain and numbness (See also E ‘Toothaches and the wisdom teeth’,
pp. 429–32)
• Swelling
• Ulceration and blistering.
Thetongue
• Bleeding/ bruising
• Change in colour/ pigmented lesions
• Hair y/ c o a t e d
• Lumps
• Pain and numbness
• Smooth, sore surface (depapillation)
• Swelling
• Ulceration and blistering
• Weak ness/ paralysis (see also E ‘Facial palsy’, pp. 340–2).
Theteeth
• Change in bite (see also E Chapter 11 and E Chapter 12)
• Discolouration/ staining
• Injury
• Too t h a che
• Wisdom teeth problems.
Thegums
• Bleedinggums
• Change in colour/ pigmented lesions
• Lumps and swelling.
The teeth andgums
• Exposedbone
• Bleeding extractionsocket
• Painful extractionsocket
• Looseteeth
• Miscellaneous— denture/ orthodontic appliance (braces)- related
problems.
COMMON PROBLEMS AND THEIRCAUSES
Common problems and theircauses
Lips:change incolour/ pigmented lesions
Common
• Benignnevus
• Haemangioma
• Actinic keratosis.
Uncommon
• Melanoma
• Perioral freckling (Peutz– Jeghers syndrome)
• Addison’s disease
• Cyanosis.
Lips:injuries
Common
• Lacerations
• Bites— animal/ self
• Foreignbodies
• Bruising/ swelling.
Uncommon
• Projectile/ blast injuries
• Fishhook.
Lips:lump/ swellings
Common
• Trau m a
• Skin abscess
• Dental infection
• Anaphylaxis/ allergic reaction
• Mucocoele/ polyps/ haemangioma.
Uncommon
• Orofacial granulomatosis
• Hereditary angio- oedema
• Dermal llers and implants
• Salivary gland tumours.
391
Lips:pain or paraesthesia
Common
• Infection
• Trigeminal neuralgia
• Neurapraxia of nerve (fracture/ lower jaw patholog y)
• Iatrogenic— dental injection or surgery/ lipbiting
• Burning mouth syndrome.
392
CHAP TER13 The mouth, lips, andteeth
Uncommon
• Shingles/ viral trigeminal neuropathy (see E Chapter 11)
• Hypocalcaemia
• MS
• Tumours.
Lips:ulceration and blistering
Common
• Primar y herpetic stomatitis/ ‘coldsores’
• Angular cheilitis
• Denture- induced trauma.
Uncommon
• Cancer (skin/ oral)
• Stevens– Johnson syndrome(SJS)
• Vesiculobullous disorders
• Shingles.
Lips:weakness orparalysis
(See also E ‘Facial palsy’, pp. 340 –2.)
Common
• Stroke
• Bell’spalsy.
Uncommon
• Other causes of facial palsy (parotid tumour/ middle ear infection)
• Iatrogenic facial nerve injur y.
Mouth:bleeding
Common
• Trau m a
• Infections
• Gingivitis.
Uncommon
• Oralcancer
• Causes of ulceration and blistering
• Haemoptysis
• Haematemesis
• Anticoagulants
• Haematological disease.
COMMON PROBLEMS AND THEIRCAUSES
Mouth:change incolour/ pigmented lesions
Common
• Normal pigmentation (Fordyce’s spot s, racial variation)
• Haemangioma/ AVM
• Amalgamtattoo
• Oral lichen planus/ lichenoid reaction
• Frictional hyperkeratosis
• Candidiasis
• Extrinsic (food stains, e.g. betel).
Uncommon
• Leucoplakia/ erythroplakia
• Cancer
• Drugs/ heav ymetals
• Hyperpigmentation— Addison’s disease.
Mouth:diculty swallowing
(See also E Chapter 8.)
Common
• Infection (odontogenic/ HSV/ mumps)
• Ludwig’sangina
• Trauma/ fractures/ sublingual haematoma.
Uncommon
• Cerebrovascular accident/ TIA
• Causes of swollen tongue/ ulceration and blistering
• Neuromuscular disorders
• Eagle syndrome
• Tumours
• Previous surgery.
393
Mouth:halitosis
Common
• Poor oral hygiene/ alcohol/ cigarettes/ dietary
• Infection (odontogenic, pericoronitis, sinusitis, tonsillitis).
Uncommon
• Bulimia
• Retained foreign body (nose/ mouth)
• GORD/ tumours in the aerodigestivetrac t
• Fetor hepaticus, lung abscess, met abolic conditions, and bowel
obstruction.
394
CHAP TER13 The mouth, lips, andteeth
Mouth:injury
Common
• Lacerations/ cheekbiting
• Denture induced.
Uncommon
• Iatrogenic
• Chemical/ thermal/ inhalation.
Mouth:lumps
(See also E Chapter 11 and E Chapter 12.)
Common
• Normal lumps (parotid papilla, submandibular duct, taste buds,
lingual tonsils)
• Fibroepithelial polyps/ haemangioma
• Nicotine stomatitis of thepalate
• Tor us
• Mucocoele
• Causes of blistering.
Uncommon
• Amyloidosis
• Orofacial granulomatosis
• Crohn’s disease
• Flabby ridge/ denture broma
• Lipoma.
Mouth:pain
(See also E ‘Toothaches and the wisdom teeth’, pp. 429–32.)
Common
• Infections (dental/ mucosal)
• Burning mouth syndrome/ atypical odontalgia
• Causes of ulceration and blistering
• Oral lichenplanus
• Herpetic gingivostomatitis
• Postoperative.
Uncommon
• Cancer
• Trigeminal neuralgia
• Angina bullosa haemorrhagica
• Osteomyelitis/ ORN/ BRONJ
• Reux oesophagitis.
COMMON PROBLEMS AND THEIRCAUSES
Mouth:swelling
Common
• Infection, abscess, Ludwig’sangina
• Sublingual haematoma
• Ranula.
Uncommon
• Anaphylaxis and allergic reaction
• Bone disease (see E Chapter 11 and E Chapter 12)
• Haemangioma/ lymphangioma
• Amyloidosis
• Orofacial granulomatosis.
Mouth:ulceration and blistering
Common
• Trau m a t ic
• Primar y herpetic stomatitis
• Aphthous ulceration
• Drug- induced (nicorandil/ chemotherapy).
Uncommon
• Oralcancer
• ORN/ BRONJ/ osteomyelitis (see E Chapter 11 and
E Chapter 12)
• SJS
• Vesiculobullous disorders
• Angina bullosa haemorrhagica
• Necrotizing sialometaplasia (palate)
• Kaposi’s sarcoma (palate)
• Syphilitic lesions (palate).
395
Tongue:bleeding/ bruising
Common
• Laceration/ tongue biting/ sublingual haematoma
• Postsurgical injection/ bleeding
• Haemangioma.
Uncommon
• Tongue piercing
• Foreignbody
• Erosive lichenplanus
• Ca n c er.
396
CHAP TER13 The mouth, lips, andteeth
Tongue:change incolour/ pigmented lesions
Common
• Oral lichen planus/ lichenoid reaction
• Frictional keratosis
• Candida/ strawberrytongue
• Poor oral hygiene/ smoking
• Antibiotics/ mouthwash (chlorhexidine)
• Alcohol/ fooddyes
• Racial pigmentation.
Uncommon
• Dysplasia/ cancer
• Amalgamtattoo
• Erythroplakia
• Haemangioma
• Hairytongue
• Melanoma.
Tongue:hairy/ coated
Common
• Frictional keratosis
• Poor oral hygiene/ smoking
• Candida
• Antibiotics/ mouthwash (chlorhexidine)
• Alcohol/ fooddyes.
Uncommon
• Black/ brown hairy tongue (lingua villosa)
• Hairy tongueofHIV
• Chronic tooth brushing to clean surface
• Pellagra.
Tongue:lumps
Common
• Fibroepithelialpolyps
• Papilloma
• Normal lumps (taste buds, lingual tonsils)
• Ranula/ mucocoele
• Chronic biting.
Uncommon
• Tumours (submucosal)
• Amyloidosis/ acromegaly
• Orofacial granulomatosis
• Lipoma/ myobroma
• Haemangioma/ AVM
• Dermoid/ ectopic thyroid.
COMMON PROBLEMS AND THEIRCAUSES
Tongue:pain or paraesthesia
Common
• Geographicaltongue
• Infection(hand, foot, and mouth disease/ coldsores)
• Trauma/ postoperative
• Causes of ulceration and blistering
• Median rhomboid glossitis
• Lichenplanus
• Drugs/ mouthwashes
• Atrophic glossitis
• Burning mouth syndrome (glossodynia).
Uncommon
• Cancer
• Trigeminal neuralgia/ glossopharyngeal neuralgia
• Reux oesophagitis
• Behçet's disease
• Vesiculobullous disorders.
Tongue:smooth, sore surface (depapillation)
Common
• Iron/ vitamin B12/ folate deciency (atrophic glossitis)
• Trauma/ friction
• Geographic tongue.
Uncommon
• Postsurgical resection/ reconstruction
• Dry mouth (xerostomia).
Tongue:swelling
Common
• Infection, abscess, Ludwig’sangina
• Anaphylaxis and allergic reaction
• Sublingual haematoma/ ranula
• Postoperative swelling.
Uncommon
• Tumour (submucosal, leukaemia, and rhabdomyoma)
• Lipoma
• Haemangioma/ lymphangioma
• Syndromic macroglossia (acromegaly/ Down syndrome/ Beckwith–
Wiedemann syndrome)
• Orofacial granulomatosis
• Amyloidosis/ myxoedema
• Neurobromatosis
• Pellagra
• Pernicious anaemia.
397